Burden and vulnerability of hypertension in a rural population of Patna, Bihar, India

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1 South East Asia Journal of Public Health ISSN: Public Health Original Research Burden and vulnerability of hypertension in a rural population of Patna, Bihar, India Rashmi Singh, Ranjeet K Sinha, Chandra Mani, Ritu Singh, Ranabir Pal Professor and Head; Assistant Professor; Junior Resident; Field Investigator; Department of Community Medicine, 5 Patna Medical College, Patna, India. Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India. Abstract Population based studies on hypertension from rural Bihar have not been reported earlier. We conducted a study to find the prevalence and the risk factors of hypertension in a rural adult population. In this cross-sectional community based study, 103 men and women, aged 30 years and above, residing at 10 randomly selected villages of Phulwarisarif Block of Patna District of Bihar were recruited. Using house to house interviews with a semi-structured pretested schedule, the sociodemographic risk factors were recorded. Hypertension and pre-hypertension were classified using JNC-VII criteria. Overall prevalence of hypertension was 3.73%; among them mean systolic and diastolic blood pressures were 144.±17.14 and 9.04±9.5 mm of Hg respectively. Among those who were hypertensive, the age cluster was higher (50.6±1.7 years) than those who were normotensive (43.±1.4 years) with a significant male preponderance. Hypertension was significantly associated with a higher body mass index, waist-to-hip ratio, along with the sedentary lifestyle. However, there was not an association with consumption of alcohol and smoking. The study highlighted the need for initiation of high risk hypertension screening in rural Bihar as the awareness on and its risk factors was very low. Key words: Hypertension, Prevalence, Risk factors, Awareness. Introduction Presently hypertension is one of the most significant global public health problems and also the most common cardiovascular health crisis in both developed and developing countries. The prevalence of the hypertension has been rising in India and other developing countries in the recent times but understanding and efforts to intervene remains miserably poor. Hypertension per se is a quiet disorder that remains usually asymptomatic until it does immense harm to the body in the form of Target Organ Damage. Hence WHO has coined the term the Silent Killer. Studies also have reported hypertension as a significant public health problem in urban as well rural areas 1-3 of India. Practice points Population based studies on hypertension from rural Bihar have not been reported earlier. There is a need for initiation of high risk The current estimated frequency of hypertension in India is hypertension screening in rural India % in the rural population and 5-30% in the urban 3 population. Hypertension is also directly responsible for much research had been done about the burden and risk 57% of all strokes deaths and 4% of coronary heart disease factors in rural areas. 4-7 deaths in India and also remains to be the leading cause of blindness, renal failure and congestive heart failure. To compound the problem, a great majority of the rural Previously thought as a disease of urban well off population, population in India has suboptimal access to healthcare and a rural infringement is nowadays increasingly being is not conscious enough to seek health care until sickness reported. The probability of escalating cardiovascular causes much distress. diseases in rural India is a public health concern and not Correspondence: Dr. (Professor) Ranabir Pal, Professor, Department of Community Medicine, Sikkim Manipal Institute of th Medical Sciences and Central Referral Hospital, 5 Mile, Tadong, Gangtok, Sikkim , India. ranabirmon@yahoo.co.in. Overall prevalence of hypertension was 3.73% with a significant male preponderance. High prevalence of pre-hypertension was also noted (11.17%). Higher BMI, waist: hip ratio along with the sedentary lifestyle was significantly associated with hypertension. South East Asia Journal of Public Health 011:1: Singh et al., publisher and licensee Public Health Foundation Bangladesh. This is an Open Access article which permits unrestricted non-commercial use, provided the original work is properly cited. 53

2 We are yet to find published studies on the prevalence of its complications were recorded. For the BMI calculation, hypertension with the associated risk factors for effective height was measured using a portable height measuring futuristic approach of the problem in rural Bihar. Therefore stand and weight was recorded using a set of bathroom this population based study was undertaken in rural scales; for the waist/hip ratio, waist and hip circumference Phulwarisharif block of Patna district, Bihar. was measured in centimeters using a single non-stretchable measuring tape. Subjects were then allowed to take rest for Methods five minutes in a sitting position, their hand rested and Study area and subjects supported on arm chair at the heart level. Blood pressure This community-based cross sectional study was conducted was measured by single investigator using the pulse in the villages of Phulwarisarif Block of Patna District of obliteration and auscultation method using the standardized Bihar from August 009 till July 010. Inclusion criteria and calibrated mercury sphygmomanometer. Those with were all men and women above 30 years present in their systolic blood pressure more than or equal to 140 mm of Hg houses at the time of visit of the team from Patna Medical and diastolic blood pressure more than or equal to 90 mm of College. Hg, those on antihypertensive medication, or those with history of hypertension were classified as hypertensive, as Sampling procedure per the Seventh Report of the Joint National Committee on With an anticipated 10% prevalence, using proportion Prevention, Detection, Evaluation and Treatment of High estimates and allowable error of 0%, the sample size for Blood Pressure (JNC VII) criteria. 3 this study was calculated as 990. Taking 10% as non response error, we tried to reach a size of 109. From the list Data analysis of 53 villages under the Phulwarisarif Block of the district, Data were entered and analyzed using SPSS Version villages were randomly selected from four sectors by a Percentages and proportions were used, and the chi square conventional lottery method. Eligible participants were test was used to find any significance. enrolled using the random number table from electoral roll of election commission of India obtained from Panchayat Results office. All these eligible individuals, identified in each of the Of the total of 1,03 participants, 3.73% were hypertensive selected villages, were met through house to house visits by (95 % CI,.-4.5) and the number increased specifically assigned teams and at least 100 members were significantly as the age of the study population increased enrolled from each village by which we were able to reach [ =54.94, df=4, p=<0.0001]. Males had a significantly 103 participants. higher prevalence in all age groups [3.39% vs. 0.65%, P<0.05] except the year group. Sex differentials were Data collection procedure also found to be statistically significant [Male: =1.9, Institution Ethics Committee of Patna Medical College df=4, p=0.01 and Female: =33.630, df=4, p=0.0001] approved the study. The health workers informed and (Table 1). motivated the families to participate in the study along with the scope of future intervention, if necessary. All the As the blood pressure level of subjects was further classified participants were informed of the purpose of the study and according to JNC VII criteria, apart from the 57 (3.73%) were ensured strict confidentiality. The participants were hypertensive individuals, 53 (49.1%) were categorized as given the option not to participate in the study if they pre-hypertensive out of which 11 (11.17%) were in the wanted. After collection of informed consent, a semi- target range of or 5-9 mm of Hg (Table ). structured pretested questionnaire was administered. Blood pressure and its determinants such as age, sex, nature of The mean age of hypertensive subjects (50.6±1.7 years) work, smoking and alcohol consumption, educational was higher than the normotensive population (43.±1.4 status, family history and awareness about hypertension and years). Systolic and diastolic blood pressure (mean±sd) Table 1: Distribution of hypertensive subjects according to age and sex Age Male Female yrs >= 70 Screened Hypertensive (%) 15 (19.4) 11 (3.35) 15 (7.7) 37 (44.05) 14 (41.1) 9 (3.39) Screened Hypertensive (%) 43 (1.95) 39 (1.93) 43 (9.45) 31 (33.70) 9 (39.13) 165 (0.65) screened hypertensive (%) 5 (14.1) 50 (0.3) 5 (.5) 6 (3.63) 3 (40.35) 57 (3.73) South East Asia Journal of Public Health 011:1:

3 prevalence of both hypertension and pre-hypertension, and their association with BMI, Waist-hip ratio and lifestyle factors. This links to the growing epidemic of cardiovascular disease, with a high prevalence of pre- hypertension shown among both sexes. Coupled with a lack of awareness and ignorance about the complications of hypertension, the situation is conducive to the perpetuation of the disease among the rural population in one of the poorer states in India. were 144.±17.14 mm of Hg and 9.04±9.5 mm of Hg respectively in hypertensive subjects as compared to 116.4±9.7 and 75.3±7 respectively in non-hypertensive subjects (Table 3). Table : Participants category based on the JNC- VII Criteria Category Normal Pre hypertensive Pre hypertensive Hypertensive Hypertensive (N = 57) Normotensive (N = 6) Mean SBP and DBP (mm of Hg) < 10 and < and/or or 5-9 >= 140 or >=90 Age (yrs) SBP (mm of Hg) DBP (mm of Hg) Age (yrs) SBP (mm of Hg) DBP (mm of Hg) Frequency Percent SBP= Systolic blood pressure, DBP= Diastolic blood pressure Various studies estimated that differential prevalence rates are due to different cut off marks in determining the level of hypertension and differing age groups in the study 9 population. The prevalence of hypertension in this study was 3.73% which is higher than the other Indian studies conducted in rural areas. Although our sample was random, the small sample size of the study may be the reason for 10-1 higher prevalence. A study conducted in rural Andhra Pradesh noted that the mean systolic blood pressure was 116 mm of Hg, diastolic blood pressure 73 mm of Hg; the 7 prevalence of hypertension was 0.3%. In a multi-centric study in rural India in1 states among people aged 0-69 Among the hypertensive patients, 59% were obese and 39% years the age standardized prevalence of hypertension was 13 pre obese. Increase of BMI was significantly associated 0% and % for men and women respectively. While 9 with the risk of hypertension [ =41, df=3, p=0.0001]. Das et al. reported 4.9% of hypertension and 35.% and 47.7% pre-hypertension in systolic and diastolic groups 14 Table 3: Mean age and blood pressure of hypertensive and respectively in West Bengal, Yadav et al. reported 3.% normotensive subjects hypertension and 3.3% pre-hypertension from Lucknow in the rural Central India. According to JNC VII, a group of pre-hypertensive people are to be targeted for primary prevention. The overall proportion of this group was 49% in the study participants with 11.17% in the target range. The probable reason for the higher prevalence of hypertension among study subjects with higher BMI is that obese individuals tend to have higher BP levels because weight increases cardiac output SBP= Systolic blood pressure, DBP= Diastolic blood pressure proportionally and also increased the peripheral resistance of arterioles. A positive association was observed between BMI and development of hypertension by other Indian Prevalence of hypertension was significantly higher 9 (35.90%) in those doing sedentary work [ =9.9, df=, researches also. p=0.007]. The differences in waist-hip ratios of hypertensive and non hypertensive subjects were found to Central obesity was significantly associated with be statistically significant. [4.14% in >1 vs..44% in <1; hypertension in the present study similar findings were =1.7, df=1, p<0.001]. However, it is apparent that reported by Yadav et al. and Kokiwar and Gupta. A strong hypertension was not associated with the consumption of and statistically highly significant association between hypertension and W/H ratio was also observed; similar alcohol [ =1.364, df=4, p=0.50] and smoking [ =5.550, 16 findings were demonstrated by White et al. and Widgren et df=4, p=0.35] (Table 4). Furthermore, 19 (11.9%) 17 individuals had a family history of hypertension out of al. The probable reason for the higher prevalence of which 3 (5.1%) developed hypertension. Nearly half of hypertension among subjects with =1 waist: hip may be due the study population (49, 46%) was illiterate and only 49 to impact of visceral (central) lipid accumulation on blood (3%) participants were aware about hypertension or its pressure level through several mechanisms of metabolic complications. However, no associations of family history syndrome. and literacy with hypertension were found. Discussions Our study on the rural population documented the high In an ICMR Indian Council of Medical Research study (ICMR) on the tea garden workers in Dibrugarh, hypertension was the most commonly observed health South East Asia Journal of Public Health 011:1:

4 Table 4: Distribution of study subjects according to risk factors BMI* Nature of Work* Hard Work Moderate Sedentary Waist : hip ratio* <1 1 Alcohol Intake Yes No Smoking Yes No *Significant Hypertensive 130 (1%) 74 (9%) 43 (39%) 10 (59%) 57 (4%) 10 (5.6%) 109 (0.57%) (35.90%) 57 (3.73%) 31 (.44%) 6 (4.14%) 57 (3.73%) 41 (.7%) 6 (4.09%) 57 (3.73%) 10 (45.45%) 57 (3.73%) 57 (3.73%) Non - Hypertensive 574 (%) 179 (71%) 66 (61%) 7 (41%) 6 (76%) 355 (74.74%) 41 (79.43%) 50 (64.10%) 6 (76.7%) 79 (77.55%) (51.5%) 6 (76.6%) 104 (71.7%) 71 (75.90%) 6 (76.7%) 1 (54.54%) 04 (75.77%) 6 (76.7%) 1 19 problem. In a recent study at Puducherry by Bharati et al., study subjects was 7.4%, higher in females (7.9%) as the overall hypertension in older generations was 47.7% compared with males (6.55%) and hypertension was (male: 37.0%, female: 55.7%). This significantly increased significantly associated with age, sex, BMI, smoking, with advancing ages; high-normal to grade-3 hypertension 9 alcohol consumption. A significantly higher blood pressure was significantly higher in the females. A sedentary was noted among randomly selected fishermen of coastal lifestyle, vegetarian diet and tobacco addiction were also West Bengal (mean age.4), who have more physical found to be significantly associated with hypertension, fitness (cardiovascular fitness) and muscle mass, but lower though previous studies in South India reported a lesser 30 percentage of body fat than the sedentary population. 19,0 prevalence (14%). In a study in rural Varanasi, the overall 1 prevalence of hypertension was 11.5%. Researchers from Cardiovascular diseases are the foremost causes for Sevagram reported a 3.41% prevalence in the rural premature death in India. In a review of Indian population while a higher hypertension prevalence rate was epidemiological studies of past 50 years, the researchers observed in females (4.6%) in contrast to males (.9%). noted that hypertension had increased gradually in rural 31 Indian researchers reported that hypertension increased with areas. Facts from developed countries show that these can increasing age, with wider variations of hypertension of up be considerably reduced by means of population-based to 50% hypertension among the older population. 3-6 policies. A multi-factorial comprehensive move towards 7 Wilking et al. observed that the prevalence of isolated global prevention of cardiovascular disease for the low and systolic hypertension appears to be greater for women than middle income countries has been recommended by the 31,3 for men, whereas a WHO Report noted a 56% prevalence. proponents of prevention. In a community-based cross-sectional study in Aurangabad, Maharashtra the overall prevalence of hypertension in the The strength of the study was that in spite of a rural background and the absence of an affluent lifestyle, 704 (65%) 53 (3%) 109 (10%) 17 (1.5%) 103 (100%) 475 (43.6) 530 (4.94%) 7 (7.0%) 103 (100%) 109 (95%) 54 (4.9%) 103 (100%) 145 (13.3%) 93 (6.61%) 103 (100%) (.03%) 1061 (97.96%) 103 (100%) South East Asia Journal of Public Health 011:1:

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